Case Studies- January 2023

Case 1:

RD is a 47-year-old man who has been taking semaglutide 0.5 mg subcutaneously weekly and metformin 1000 mg orally twice daily for type 2 diabetes. When he tried to refill his semaglutide, he was told that his dosage is on national back order because demand for the product is exceeding the manufacturer’s supply. RD called his insurance provider and learned that liraglutide (Victoza; Novo Nordisk) is a covered alternative. RD’s primary care provider calls the pharmacist with questions on how to appropriately switch between the 2 products.

What should the pharmacist recommend?

The pharmacist can recommend the following approach: discontinue semaglutide; initiate liraglutide 7 days after the last dose of semaglutide; start liraglutide at an equivalent dose, such as 1.8 mg daily, or a lower dose; and titrate according to package instructions.1 RD should report any changes in bowel habits as well as dyspepsia, nausea, or vomiting because gastrointestinal symptoms vary between glucagon-like peptide-1 agonists. If gastrointestinal symptoms occur, the dose of liraglutide can be lowered and titrated more slowly. Also remind RD that although he previously used semaglutide weekly, he will now need to inject liraglutide once daily with or without food. He should continue to monitor his blood sugar at home and report any concerns to his primary care provider.

Case 2:

AM is a 30-year-old woman who wants to quit smoking cigarettes using nicotine replacement therapy (NRT). She takes medications for allergic rhinitis, asthma, and atopic dermatitis. AM smokes her first cigarette within 30 minutes of waking each day, and she smokes 15 cigarettes per day. After the pharmacist discusses NRT options with AM, she is not sure whether to use the NRT oral inhaler, lozenge, or patch.

Which should the pharmacist recommend?

Because AM has dermatitis, using the patch may not be advisable, as it can increase skin irritation. Additionally, because of her asthma, she should avoid the oral inhaler or use it with caution because it can cause bronchoconstriction. Prior to making firm recommendations on the products, the pharmacist could further explore the severity of AM’s eczema and obtain more information about the triggers. However, to avoid safety concerns, the pharmacist’s best recommendation is lozenges. Based on AM’s tobacco use, the pharmacist can recommend one 4-mg lozenge to be taken every 1 to 2 hours, for a maximum daily dose of 20 lozenges per day.1 Advise AM to place the lozenge between the cheek and gums and let it dissolve slowly. She should not drink or eat for 15 minutes prior to or while taking the lozenge.

About the Author

Stefanie C. Nigro, PharmD, BCACP, CDCES, is an associate clinical professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.